Download The Federal Agency in Health Protection and Social Development

The Federal Agency in Health Protection and Social Development
The Stavropol State Medical Academy
The Department of General Surgery
PREOPERATIVE PERIOD. OPERATION. POSTOPERATIVE PERIOD.
For Students of General Medicine of the English-speaking Medium
Stavropol 2009
УДК 616-0.89 (07.07)
ПРЕДОПЕРАЦИОННЫЙ ПЕРИОД. ОПЕРАЦИЯ. ПОСЛЕОПЕРАЦИОННЫЙ
ПЕРИОД. (Для студентов лечебного факультета англо-язычного отделения).
Ставрополь: Изд-во СтГМА. – 2009.
PREOPERATIVE PERIOD. OPERATION. POSTOPERATIVE PERIOD.
(For Students of General Medicine of the English-speaking Medium). Stavropol:
St.SMA. – 2009.
Cоставители:
Владимирова О.В., ассистент кафедры общей хирургии Ставропольской
государственной медицинской академии.
Линченко В.И., к.м.н., ассистент кафедры общей хирургии
Ставропольской государственной медицинской академии.
Данное учебное пособие представляет собой комплекс наиболее
необходимой информации для студентов 3 курса лечебного факультета при
изучении темы предоперационной подготовки, процесса операции,
послеоперационного периода. Предназначено для студентов англоязычного
отделения медвузов.
Рецензенты:
Лаврешин П.М., д.м.н., профессор, зав.кафедрой общей хирургии
Ставропольской медицинской академии.
Знаменская С.В., к.пед.н., доцент, зав.кафедрой иностранных языков с
курсом латинского языка, декан факультета иностранных студентов
Ставропольской государственной медицинской академии.
УДК 616-0.89 (07.07)
Рекомендовано к изданию Цикловой методической комиссией по
англоязычному обучению иностранных студентов Ставропольской
государственной медицинской академии
© Ставропольская государственная медицинская академия, 2009
Introduction
1. The preoperative period encompasses the time between the patient's admission to
the hospital and start of the operation.
The duration of the period may vary with a number of factors, such as:
• type of disease;
• severity of the patient's condition;
• nature of the surgery.
The main purposes of the preoperative period are as follows:
1) to define the problem (i.e. to make the diagnosis);
2) to identify other conditions that may influence anaesthesia or surgery (i.e. to
determine the indications and contra-indications, urgency and type of operation to be
performed);
3) to prepare the patient for the operation (to minimise the risk associated with the
surgery and that of postoperative complications):
• to evaluate the functions of all body systems (including the operative site) and thus
to prevent their deterioration;
• to identify and, whenever necessary, eradicate endogenous infection;
• to prepare the patient psychologically;
• to choose and provide the patient with appropriate anaesthesia.
Depending on the urgency operations are classified as:
1. Emergency operations should be performed either immediately or within several
hours after the patient's admission to the surgical unit.
2. Urgent operations are to be undertaken within a few days after admission.
3. Elective operations are those that have been previously scheduled.
DETERMINING THE URGENCY OF SURGERY
The time within which an operation has to be performed varies with indications that
fall into the three categories: life-saving, absolute and relative.
Life-saving indications imply that the least delay in performing the operation would
result in the patient's death. The following may serve as examples: 1. Sustained
bleeding due to
• rupture of internal organs (e.g. the liver, spleen, kidney, uterine tubes in an ectopic
pregnancy);
• injury to major vessels;
• gastric and duodenal ulcers.
2. Acute abdominal infections (e.g. acute appendicitis), strangulated hernias, acute
intestinal obstruction or thromboembolism (as they can result in pyogenic peritonitis
or gangrene in the case of thromboembolism)
3. Pyogenic, or suppurative, infections such as abscess, phlegmon, pyogenic mastitis,
acute osteomyelitis, etc. (as they increase the risk of generalised infection, or sepsis).
Absolute indications emerge when the absence or delay of surgery can be lifethreatening. Such operations are performed within a few days or weeks after
admission. Among the conditions are malignant tumours, pyloric stenosis,
mechanical jaundice, chronic lung abscesses, etc. Unjustifiable delay in operating can
lead to tumour metastases, cachexia, liver failure as well as other complications.
Relative indications such as hernias, superficial varicose veins of the lower
extremities, benign tumours usually require scheduled surgeries rather than
emergency ones.
When assessing the indications for surgery, possible contra-indications are to be
sought: respiratory, cardiac or vascular insufficiency (shock), cardiac infarctions,
strokes (cerebrovascular accidents), hepatic failure, thromboembolism, severe
metabolic disorders (unstable diabetes mellitus, diabetic ketoacidosis or coma),
severe anaemia, marked cachexia. These changes must be evaluated in terms of the
extent and risk of the forthcoming surgery.
To accomplish this, a comprehensive evaluation of the patient should be performed.
For instance, if the patient has an underlying or concurrent disease, a relevant
specialist (internist, neurologist, etc.) should also assess their condition.
In the case of relative indications associated with a concurrent condition that
increases the hazard of surgery, it is usually delayed to restore the function affected,
whereas the preoperative workup in the case of absolute indications consists in
compensating for the functions involved.
If a life-saving operation is to be performed (i.e. the preoperative period is confined
to several hours), the preparation will be completed by a team of specialists- the
surgeon, anaesthesiologist and internist. The joint decision should be made on the
extent of operation, method of anaesthesia, drug and infusion therapy to use.
In a critically-ill patient, the extent of surgery should be minimal and directed at
saving the patient's life (e.g. cholecystostomy rather than cholecystectomy in acute
cholecystitis; colostomy in acute intestinal obstruction due to a large bowel tumour,
etc).
Similarly, the anaesthetic method is to be chosen on an individual basis,
neuroleptanalgesia being commonly preferred. In patients with a respiratory disease,
for instance (e.g. bronchial asthma) Halothane is recommended, while in those with
cardiac problems it would be more appropriate to apply local anaesthesia with
potentiation.
Additional preoperative workup
1. Reviewing data of anamnesis and symptoms helps to find out the clues for further
management of the patient. For example, thirst, the amount of fluid and/or blood loss
as a result of vomiting and/or external bleeding should be taken into consideration.
Likewise, of crucial importance are allergic and drug anamnesis (particularly the
tolerance of previous intravenous fluids) as well as concurrent hepatic or renal
insufficiency (including the character of micturition and urinary volume).
2. Examination of the skin and visible mucous layers aids to reveal cutaneous
dryness and collapse of the superficial veins, suggestive of dehydration and
circulating blood volume depletion. Besides, acrocyanosis and marble discoloration
of the skin are the signs of microcirculatory deficiency and respiratory failure.
3. It is a must to check for the pulse rate and char-acter, arterial blood pressure and
central venous pressure in critically-ill patients (which is normally between 50—150
mm of water level); electrocardiography should also be obtained. Moreover, the
depth and rate of breathing, dyspnoea are to be assessed, murmurs and abnormal
breath sounds being noted on cardiac and pulmonary auscultation, respectively.
To evaluate renal function, daily diuresis (normal, 30—40 ml per hour) and the
urinary specific gravity are to be measured.
The assessment of homeostasis requires serial checks of haemoglobin and
haematocrit values, as well as acid-base equilibrium, the levels of major ions (K+,
Ca2+, Mg2+, CI‾), circulating blood volume and its components. The homeostatic
changes occur in different types of surgical conditions (trauma, hemorrhage, surgical
infections) and are therefore nonspecific.
In emergency, laboratory investigations should be minimal so as not to delay the
operation. After the diagnosis has been made, the routine blood and urine analyses
help determine the severity of infections, if any, and the degree of blood loss (based
on haemoglobin and haematocrit values), the urine analysis being also used to assess
renal function. If possible, the blood electrolyte levels and circulating blood volume
are to be evaluated, as these dictate anticipated intravenous fluid therapy either to
detoxicate patients with pyogenic infections or replace blood volume in those with
haemorrhage.
Assessment of surgical and anaesthetic risks
As both surgery and anaesthesia pose potential risks to the patient, their objective
assessment is very important. It helps determine the indications for surgery and
choose the appropriate surgical and anaesthetic techniques, which, in turn, reduces
the perioperative risks. To do this, the scoring system is frequently used. When
assessing the anaesthetic risk, the three aspects should be considered, namely the
patient's general condition, the extent and type of the surgery, the anaesthetic
technique.
1. The patient's general condition:
a) satisfactory: the otherwise healthy patient— 0,5 points;
b) fair, the patient with a mild systemic disease — 1 point;
c) severe: the patient with severe disease that limits activity but is not incapacitating
— 2 points;
d) critical: the patient with an incapacitating disease that is life-threatening — 4
points;
e) terminal: moribund patient not expected to survive 24 hours with or without
surgery — 6 points.
2. The extent and type of the surgery:
a) superficial operations and those for mild infections — 0,5 points;
b) more complex superficial operations and the ones on the viscera, spine and
peripheral nerves, and vessels — 1 point;
c) prolonged and invasive surgeries on the viscera in traumatology, urology,
oncology, and neurosurgery — 1,5 points;
d) cardiac and major vascular surgeries, major operations in oncology, repeated and
reconstructive surgeries - 2 points;
e) complex cardiac surgeries using extracorporeal circulation technique (coronary
artery bypass, cardiac transplantation) — 2,5 points.
3. The anaesthetic technique:
a) local potentiated anaesthesia - 0,5 points;
b) regional spinal, epidural, intravenous anaesthesia, inhalation mask anaesthesia
with spontaneous breathing — 1 point;
c) standard combined endotracheal anaesthesia — 1,5 points;
d) endotracheal anaesthesia combined with artificial hypothermia, controlled
hypotension, massive infusion therapy, electric cardiac stimulation — 2 points;
e) endotracheal anaesthesia combined with extracorporeal circulation using a heartlung machine (e.g. coronary artery bypass), hyperbaric oxygenation, intensive care
and resuscitation — 2,5 points.
Further, the risk is assessed based on the sum of points:
• degree 1 (minimal risk) — 1,5 points;
• degree 2 (moderate risk) — from 2 to 3 points;
• degree 3 (high risk) — from 3,5 to 5 points;
• degree 4 (extremely high risk) — from 8,5 to 11 points.
In emergency, the preoperative period is very short (e.g. heart injuries, massive
internal bleeding) with the patient being immediately admitted to the operating
theatre. Preparation of the patient for elective surgery is started before he/she arrives
at the surgical unit.The outpatient surgeon or physician is to promptly determine the
preliminary indications for surgery, order the pertinent additional investigations to
establish the diagnosis, and psychologically prepare the patient for the impending
surgery.
Whatever vital function disorders (e.g. haemorrhage) require that the surgeon start
emergent management - control of bleeding and giving vasopressor and/or
vasodilator agents. These will be continued during the patient's transportation to the
surgical unit and are considered the preoperative care.
Contraindications. The laboratory findings help assess the patient's general condition,
reveal concurrent diseases and thus determine the contraindications, if any, for the
operation.
The absolute contraindications include the following:
• shock (other than that resulting from sustained bleeding);
• acute myocardial infarction;
• stroke.
The relative contraindications involve as follows:
• congestive heart failure;
• cardiac arrhythmia;
• ischaemic heart disease;
• respiratory failure;
• bronchial asthma;
• chronic renal failure;
• hepatitis;
• anaemia;
• leukaemia;
• diabetes mellitus.
Assessing the contraindications for the operation the surgeon should take both the
indications and the risk degree into consideration. Currently, each situation with
absolute indications for surgery can virtually always be resolved.
Psychological preparation for surgery
The surgeon should provide a clear explanation of the planned course of therapy. The
patient must be informed of the risks of the proposed treatment, the risks of the
underlying disease, and plausible therapeutic methods.
The psychological preparation is mainly aimed at clarifying the necessity and
instilling hope for a successful outcome of the surgery. Especially is this necessary
when a patient refuses the operation as a result of their incomprehension of the
severity of their condition (e.g. acute appendicitis, strangulated hernia, perforated
peptic ulcer, intra-abdominal bleeding due to a rupture of ectopic gestation, or the
spleen or liver, penetrating injuries to the abdomen, chest) in which case a delay in
surgery can lead to severe peritonitis or pleuritis, blood loss and irreversible
consequences.
Physiologic preparation for surgery
Even though an urgent surgery is needed, the existing organ failures should always be
corrected prior to, during or following the surgery, otherwise the favourable outcome
of the treatment is unlikely.
The preoperative workup should be as short and efficient, in emergency being
primarily aimed at reducing hypovolaemia and tissue dehydration. In patients with
hypovolaemia, electrolyte and acid-base imbalances, infusion therapy including
intravenous solutions of polyglucin, albumin, protein (and sodium bicarbonate in
those with acidosis) with cardiovascular agents is immediately to be provided. To
correct metabolic acidosis resulting from diabetes mellitus concentrated solutions of
glucose with insulin are given.
In acute haemorrhage (and after the bleeding has been controlled) intravenous
administration of polyglucin, albumin, and plasma is indicated. In sustained massive
bleeding intravenous fluid therapy will be started with cannulas placed at least in two
peripheral veins simultaneously while thepatient is being transferred to the operating
room where he/she is operated on to stop the bleeding. Intravenous fluid therapy is to
be continued throughout surgery.
Emergency management of shock (traumatic, toxic or haemorrhagic with the
bleeding already controlled) is aimed at:
a) eliminating the shock factor (pain control in traumatic shock; bleeding control in
haemorrhage; detoxication therapy in toxic shock);
b) restoration of the circulating blood volume by way of intravenous fluid therapy;
c) restoring vascular tone with vasoconstrictors.
In most cases, surgery can be started with systolic blood pressure of at least 90 mm
Hg. In the cases of haemorrhagic shock and sustained internal bleeding the surgery
may be started before the patient's circulatory parameters have been corrected as the
causative factor of the shock — bleeding - can definitively be controlled only by
operating on the patient.
The physiologic preparation for the surgery must include the following:
1. Estimation of the surgical risk associated with the underlying circulatory disorders,
diagnosis and management of the preoperative cardiovascular problems (e.g.
preparations that improve microcirculation (rheopolyglucin).
2. Prevention and treatment of respiratory distress (oxygen therapy, improvement of
pulmonary circulation, and mechanical ventilation in severe cases).
3. Detoxication therapy — fluid infusion, blood substitutes with detoxicating
properties, forced diuresis with specific techniques — hemabsorption, lymph
absorption, plasmapheresis and oxygen therapy.
4. Correction of fluid, electrolyte, and acid-base disorders.
Intravenous fluid therapy is aimed at restoring the circulating blood volume,
eliminating dehydration, and normalising fluid, acid-base and electrolyte balances.
Therefore, in hypovolemia, electrolyte, and acid-base imbalances the abovementioned therapy is a matter of urgency (see Chapter VI).
Also, the preoperative period may require that a number of manipulations be
performed. If, for instance, the patient ate the previous day or shows the signs of
intestinal obstruction, the stomach is to be lavaged before the operation to prevent
vomiting or regurgitation during general anaesthesia.
Stomach lavage. To perform gastric washout the following equipment is needed: a
nasogastric tube, funnel, bowl, plastic apron, pair of gloves, a cup and jug with boiled
water. The patient's condition permitting, he/she is made to lie (or sometimes sit on a
chair); the end of the tube will be lubricated with vaseline and inserted into the
patient's throat (theyshould try to swallow the tube while the physician passes it into
the oesophagus). On reaching the first mark on the tube (50 cm) the end appears at
the cardiac portion of the stomach. If the stomach is full, the contents start gushing
out immediately and are thus to be directed into the bowl. When the spontaneous
flow stops, a glass funnel will be attached to the outer end with subsequent aspiration
of the gastric contents. To do this, the funnel is raised 20— 25 cm above the mouth
level and 0,5—1 1 of water that passes into the stomach is poured into the funnel. To
prevent air from entering the stomach, the water must flow continuously. When all
the water in the funnel has been emptied into the stomach, the tube with the funnel
still attached is then lowered into the bowl (below the knee and bed levels for the
patient sitting and lying, respectively) with the funnel cup in an upward position.
After the funnel has been filled up with the gastric contents it is emptied into the
bowl or bucket. If the amount of fluid emptied is less than that given, the position of
the tube is changed — it can be pushed a little further or pulled back, the funnel being
either gently pushed down or pulled out. Thereafter, the contents usually starts to
flow out, the procedure being repeated after the gastric contents have stopped
flowing. The stomach should be washed until clear water starts flowing out.
When the flow stops, irrigating syringe has to be used — pour with force and aspirate
the water, the procedure being repeated several times. As a matter of fact, pieces of
food particles that cause obstruction are evacuated in this process; alternatively, the
tube can be removed and reinserted.
Finally, the tube is to be removed gently into a napkin placed at the patient's mouth.
Insertion of urethral catheter. The procedure is applied preoperatively to empty the
bladder in urinary retention, monitor the urine output during operation and prevent
bladder injury during pelvic surgery or laparoscopy.
The equipment required includes a sterile rubber catheter, two sterile forceps, sterile
vaseline oil, gauze swabs, furacilin solution 1:5000 or 2% boric acid. All these are to
be placed on a sterile tray. The hands are washed with running water and soap, and
cleansed with alcohol for 3 minutes.
The male patient is put supine with his legs bent in the hip and knee joints and
opened apart. The tray or pot for the collection of urine is placed in between the
patient's legs. The urethral meatus and the surrounding areas are cleansed thoroughly
with gauze swabs dipped into antiseptic. Using the forceps the catheter is picked 2—
3 cm from the end and dipped into the sterile vaseline oil. The left hand (between
fingers 3 and 4) is used to fix the penis whilefingers 1 and 2 to open the outer end of
the urethra. Using the forceps, the catheter is inserted into the urethra and
subsequently into the bladder. Passing through the isthmus of the urethra the catheter
can encounter resistance. Once the catheter is in the bladder, urine should flow freely
into the disposable basin provided. The volume, colour and turbidity of the urine are
noted. The catheter is removed after the bladder has been completely emptied.
When the bladder cannot be emptied with the soft catheter, a metallic one should be
used, which, however, requires much experience for the danger of injuring the
urethra.
Passing the catheter in a female patient is technically easier since the female urethra
is shorter, wider and straighten It is performed with the woman supine and her legs
apart. The patient lies on the bad-pan. Running water is used to wash the perineum,
the smaller lips being opened with the left hand fingers. Cotton swabs soaked in
antiseptic are used to cleanse the external urethral meatus. With the right hand and
forceps the catheter is passed into the urethra. A metallic catheter for women can be
used, which is held in such a way that the beak points upwards. The catheter is easily
inserted until urine appears. On emptying the bladder the catheter is removed.
Enema. To perform a cleansing (purgative) enema the following items are necessary:
Esmarch's cup with a rubber tube, a tap or clamp, and a glass or plastic tip (endpiece). 1 — 1,5 1 of water are poured into the cup and fills the tube to evacuate all the
air, the tube is then closed with the tap or clamped at its end. The tip (end piece) is to
be lubricated with vaseline or oil. The patient will be placed on the left side (on the
side of the sigmoid colon) to insert the tip into the rectum 10—15 cm deep. The
clamp is then removed or the tap opened and the cup gradually raised. After the water
has started flowing slowly into the rectum, the end piece is removed and the patient
turned to lie supine on a bed pan or receiver (they are made, if possible, to sit on the
closet). It is recommended that the water be allowed to stay as long as possible in the
rectum before evacuation.
Cleansing («siphon») enema. This type of enema is indicated when ordinary enemas
are ineffective in evacuating faeces (intestinal obstruction, faecal impaction). The
equipment used for the cleansing enema includes a rubber or plastic tube fitted onto a
large glass funnel. The patient should be placed on their left side at the edge of the
bed or couch. The funnel will be filled with water, the clamp opened to drive away
the air and then closed again to fill up. The tip of the rubber tube is inserted into the
rectum 10—12 cm deep, the clamp being removedand the funnel raised to allow the
water to flow into the large intestine. 2—3 1 of water are usually passed at a time,
with constant pouring it into the funnel so as to avoid a break in the flow of water and
to prevent air from entering the intestine. When the patient expresses the urge to
defaecate the funnel is lowered below the bed level and the water flows out together
with the faeces and air. When filled up, the funnel is emptied. Filling with water and
evacuating the intestinal contents are repeated several times, using totally 10—15 1
of water. Such signs as massive evacuation of the faeces and gases, a relief of pain
and reduction in abdominal distension in patients with intestinal obstruction are
favourable.
Prevention of endogenous infection. All chronic infections (e.g. tooth decay,
tonsillitis, pharyngitis and pyogenic dermatitis) should be sought and treated
preoperatively. When the impending surgery has a relative indication, the patient can
be discharged to eradicate the infection before admission back to the surgery.
The surgery for a lung abscess involves bronchoscopy to remove, at least initially,
inspissated purulent debris. For the patients to be operated on for a large intestinal
condition a soft diet, cleansing enema and oral broad-spectrum antibiotics for a few
days preoperatively are ordered.
In addition, the patient will be examined by the anaesthetist who prescribes the
appropriate anaesthetic technique.
Preliminary preparation of the operative field. On the day preceding that of the
operation a cleansing enema is performed, the patient takes a hygienic bath and
changes into clean fresh underwear; immediately before transfer of the patient to the
operating theatre the exposure area will be dry-shaved.
The operative field should be prepared differently in case of an ulcer or wound: the
dressing is removed and the wound is covered with a sterile dressing, the skin around
the wound being cleansed with benzene or ether and the hair dry-shaved. All
movements — cleansing the skin or shaving the hair — must be directed outward
from the wound so as to reduce the risk of contaminating the wound. On shaving, the
dressing should be removed and the surrounding skin cleansed with 5% alcohol
solution of iodine, with the wound being covered with sterile dressing.
Anaesthetic technique. Before the patient is taken to the operating theatre he/she is
given specific drugs to reduce the risk of adverse effects of anaesthesia and surgery
itself, as well as to avoid negative events intra-operatively.
Transferring the patient to the operating theatre.
A patient is usually transferred to the operating theatre on a stretcher. In emergency,
providing endotracheal anaesthesia via intubation is continued if the patient has been
previously intubated, with simultaneous mechanical pulmonary ventilation.
If the tourniquet has been applied for external bleeding, the patient is taken to the
theatre with it, the tourniquet being removed immediately before the operation.
Similarly, the patients with open fractures are admitted to the operating theatre with
the dressing originally placed on the wound as well as the transportation splint intact.
The cases with acute intestinal obstruction will be admitted to the theatre with a
nasogastric tube.
A surgical patient is gently transferred from the stretcher to the operating table
together with the intravenous infusion system, tourniquet or transportation splint, and
is positioned as required.
The surgical team includes:
the surgeon
assistant (there can be several of them)
surgical nurse
anesthesiologist
anesthetic nurse.
The operation block is separated from other divisions of the hospitals with an
anteroom which is passed only by authorized personnel, after certain precautions.
The operation block is divided into a number of divisions, regimen zones:
Sterile zone – operation theatre, sterilization room
Strict regimen zone – scrub room, anesthetic room, storage room. The entrance is
marked with a red line; it is crossed only in surgical uniform
Restricted zone – blood storage and equipment room, nurses’ room
General regimen zone – offices of the department head, of head nurse, dirty linen
room.
The underlying principle of the regimen of the operation block is that man is the main
source of microbial flora; so the fewer people are in the room, the less infection. The
personnel of the operation block should wear surgical suit, shoes and caps. Before
entering the strict regimen zone the gown worn over surgical suit is taken off; in the
sterile zone a 4-layer mask and shoe covers are put on. Personnel not participating in
the operation cannot come into the surgical unit.
The main equipment of the operation theatre is:
operation table
shadowless ceiling lamp with reflectors
mobile light
anesthesia machine
anesthesia table (with anesthetic kit and drugs)
large instrument table
mobile instrument table
drums
bactericidal lamps
electrocoagulator
monitoring equipment.
Only objects used for the operation can be present in the operation theatre.
Positioning the patient for surgery.
positioning is important to:
(1) adequately expose the operative area;
(2) make the patient accessible for induction of anesthesia and administration of
intravenous solutions or drugs;
(3) minimize interference with circulation due to pressure on a body part;
(4) provide protection from injury to nerves due to improper positioning of arms,
hands, legs, or feet;
(5) provide for the maintenance of respiratory function by avoiding pressure on the
chest to allow for adequate ventilation of the lungs and by holding the jaw forward to
keep it from dropping on the chest;
(6) provide for the patient's individuality and privacy by proper draping.
Supine position. In the supine position the patient lies flat on the back with arms at
the sides, palms down with fingers extended and free to rest on the table, and legs
straight with feet slightly separated. This is the most commonly used position in the
operating room and is used for hernia repair, exploratory laparotomy, cholecystectomy, gastric and bowel resection, and mastectomy. Attention must be given to
proper support of the patient's neck and jaw to assure the maintenance of a patent
airway.
Prone position. In the prone position the patient lies on the abdomen with the face
turned to one side and arms at the sides with palms pronated and fingers extended.
The arms should be well protected and carefully positioned to prevent ulnar or radial
nerve damage. Elbows may be slightly flexed to prevent overextension of the shoulders. The patient's feet should be elevated off the table with a small pillow or blanket
roll to prevent plantar flexion and pressure on the toes. Body rolls should be placed
under each side of the patient to raise the chest and permit the diaphragm to move
freely and the lungs to expand. When the patient is in the prone position, the restraint
strap is placed below the knee. It is important that the patient's head and neck be
positioned properly to assure a patent airway. This position is used for surgery on the
back, spine, and rectal area. The patient is anesthetized in the supine position and
then placed in the prone position. This position should be assumed gradually, and
usually four persons are required to turn the patient safely. Details of the turning
process can be found in specialized texts and articles.
When the surgery is completed, the patient will be returned to the supine position.
This should be done gradually and slowly to allow the patient's cardiovascular system
to adjust to the change in position. Rapid turning of the patient can cause a
precipitous drop in the blood pressure.
Trendelenburg position. In the Trendelenburg position the patient's head and body are
lowered into a head-down position. The knees are flexed by "breaking" the table, and
the patient is held in position by padded shoulder braces. This position is used for
operations on the lower abdomen and the pelvis to obtain good exposure by a
displacement of the intestines into the upper abdomen. The upward position of the
viscera decreases the movement of the diaphragm and interferes with respiratory
excursion. For this reason this position is not maintained any longer than necessary.
The operating room table should be returned to a normal position very slowly so that
the patient's cardiovascular system has time to adjust to the shift in position. When
the patient is in the Trendelenburg position, blood pools in the upper torso and the
blood pressure rises. As the patient is lowered to a normal position, the venous supply
is shunted to the legs, and a sudden drop in blood pressure may occur.
Reverse Trendelenburg position. As the name implies, in the reverse Trendelenburg
position the head is elevated and the feet are lowered. This position may be used to
obtain better visualization of the biliary tract in surgery. The patient must be properly
supported by a footboard, body restraints, and a lift sheet around the arms. Since
blood will tend to pool in the lower extremities, caution should be used in slowly
returning the patient to a normal position. A sudden influx of the pooled blood from
the feet can cause an overloading of the cardiovascular system. Obviously this would
be of most concern in elderly patients or in those with preexisting cardiovascular
problems.
Lithotomy position. In the lithotomy position the patient lies on the back with the
buttocks to the break in the operating table. After the patient is anesthetized, the
thighs and legs are flexed at right angles and then simultaneously placed in stirrups.
This prevents injury, which can occur to the muscle if each leg is flexed and placed in
the stirrup separately. The hands and arms may be placed over the patient's chest and
secured by the gown or positioned on armboards at the side. They should not extend
beyond the break in the table, since they may be injured when the table is
manipulated. The lower section of the table is then lowered. This position is used in
perineal, rectal, and vaginal surgery.
In this position the patient has blood from the legs shunted into the torso and upper
extremities. If the patient must remain in the lithotomy position any period of time,
Ace bandages are often wrapped around each leg prior to surgery to lessen pooling
and thrombus formation. Because of increased pressure on the sacral area, these
patients may also develop pressure areas with redness and maceration of the skin.
When the surgery is completed, the patient's legs must be gradually returned to a
normal position. As in the Trendelenburg position, rapid lowering of the legs may
cause a sudden drop in blood pressure as part of the total blood volume is shunted
back into the legs.
Lateral positions. Various versions of the lateral position are used for surgery on the
kidney and the chest. The kidney position is used for nephrectomy and
pyelolithotomy. As can be seen, this position puts pressure on the lower arm and leg,
and blood pools in these areas. The position of the chest allows the upper lung to
move more freely than the lower lung. This can interfere with pulmonary ventilation,
since the two lungs function differently.
Other positions. Special positions may be necessary to place the operative site in the
best possible position. One example of this would be the thyroid exposure. In this
position the patient lies on the back with the head hyperextended and a small
sandbag, pillow, or thyroid rest under the neck and shoulders to provide exposure of
the thyroid gland. Special operating tables and attachments are frequently used for
genitourinary, rectal, bone, endoscopy, and brain surgery. The operating room nurse,
anesthesiologist, and surgeon must be well informed in the use of such tables and
attachments and be aware of the desired position for each surgical procedure.
In the past few years more attention than ever has been paid to the proper positioning
of the patient to minimize the physiologic changes that occur in the sedated and anesthetized patient. The nurse who is aware that these changes can occur will be more
alert to situations in the operating room that can adversely affect the recovery of the
patient.
Prevention of the exogenous infection: Important role in satisfaction of the
procedures plays preparing of the premise and people for operation.
Types of cleaning the operation theatre:
Preliminary cleaning is done in the morning by wiping all horizontal surfaces with a
wet cloth with disinfectant
Routine cleaning is done during surgery by picking all instruments dropped on the
floor, used napkins and swabs; spilled blood and other fluids are wiped
concluding cleaning: when surgery is completed, the infected materials are disposed
or disinfected; pre-sterilisation treatment of instruments is done; the oilcloth on the
table and the floor around it is cleaned.
At the end of the day the floor and the walls, all surfaces of equipment are washed
with disinfectants.
On the day of the thorough cleaning no operations are scheduled. The operation
theatre is cleared of all equipment and the ceiling, floor, walls, windows, doors are
washed with disinfectant solutions.
All other premises in the surgical unit are cleaned twice a day: preliminary and
concluding cleaning.
The surgeons and sister should prepare for operation using methods of antisepsis and
asepsis.
Surgical disinfection of hands. The objective of surgical disinfection is to free the
hands from microorganisms reliably for a long time. Its underlying principle is
mechanical cleaning followed by disinfection.
The hands and forearms are first scrubbed with soap for 3-5 minutes, and then
disinfected with a solution.
Preparations used for disinfection of hands should answer the following
requirements:
Kill off pathogenic flora on the skin surface quickly.
Kill off microorganisms in the glove liquid quickly and reliably, so that the hands are
sterile during the whole surgery procedure.
Have a cumulative effect: frequent use of one disinfecting agent should reduce the
amount of bacteria so that the surgeon’s hands are bacteria free in the period between
disinfection procedures.
Non-irritant for the skin.
The following disinfecting agents are recognized as appropriate: alcohol (70 % ethyl
alcohol, 60% propanol, 70% isopropanol), mixed alcohol and iodophor (iodopyrron,
iodonate), performic acid or pervomur, 0.5% chlorhexidine solution.
The classical Furbringer’s or Spasokukotsky-Kochergin methods and others are not
in wide use nowadays as they take a long time.
For skin preparation before surgery sponge it twice with 2% iodine alcoholic solution
and then with 70 % alcohol solution.
An operation, or a surgery, is a specific mechanic intervention upon a part of the
body for diagnosis or treatment.
Surgeries are commonly classified depending on their urgency and the chance of
curing the patient.
Depending on the urgency, there are the following types of operations.
Urgent, i.e. the ones to be performed immediately or within a few hours following the
patient's admission.
Emergency, i.e. the ones that should be done within several days after the patient's
admission.
Scheduled, i.e. the ones performed according to schedule (the date of the operation is
not fixed).
Each operation may be either radical or palliative:
Radical, i.e. the one intended to extirpate the disease, usually malignant, completely.
Palliative, i.e. the one intended to relieve symptoms without hope of cure.
An operation can also be a one-stage or multistage surgery. Each step of a one-stage
operation follows the previous one in succession, while a multi-stage operation
consists of a series of surgeries performed on different days.
Current methods of anaesthesia and intensive care allow for two or more operations
be done simultaneously in the same patient.
Microsurgery requires that the object to operate on be magnified at least 3- to 40-fold,
which is achieved with special glasses or a microscope and that special microsurgical
instruments and the thinnest sutural strips be used.
Endoscopic (e.g. laparoscopic, thoracoscopic) operations are performed with special
devices.
Endovascular operations are closed intravascular interventions done under the X-ray
control, e.g. widening a narrowed vessel with a special catheter; removing artificial
occlusion of the vessel, or embolization; elimination of intravascular atheromata, etc.
The surgical operation consists of following main steps:
operative access;
primary step (operation itself);
finishing the operation, suture of wound.
All the events associated with the operation itself, including the operation stress and
effect of anaesthesia, are referred to as the postoperative period, while the
consequences of surgery are called as the postoperative condition, or «postoperative
disease».
The operation stress caused by the surgery results from various factors such as fear,
excitement, pain, the effect of anaesthetics, trauma, wound formation, abstinence
from food, being bed-ridden, etc.
The development of a stressful state is promoted by the following factors:
The patient's general status before and during the surgery, which depends on the type
of disease.
The traumatic nature and duration of the surgical manipulation.
Inadequate anaesthesia.
In terms of its duration, the postoperative period encompasses the period from the
end of the operation up to the patient's complete recovery or his/ her recognition
being disabled.
The following stages of the postoperative period are identified:
early postoperative period (from the end of surgery to the time the patient is
discharged from hospital);
late postoperative period (from the time the patient is discharged till the time he/she
recovered fully or is found disabled).
Both surgery and anaesthesia bring about particular pathological changes in the body,
which are the manifestations of the body's response to the surgical trauma. This
induces defensive mechanisms to eliminate the consequences of the trauma and there-
fore restore homeostasis. The surgery affects the balance in the rate of metabolic
(anabolic and catabolic) reactions rather than launches new metabolic events. The
postoperative state divides into the three phases:
catabolic phase;
resolution phase;
anabolic phase.
The catabolic phase lasts three to seven days. The period tends to be more acute when
the serious changes in the body are caused by the severity of the principal condition
or the extent and hazards of the surgery itself. The catabolic stage may also be prolonged and worsened if postoperative complications develop. These include the
following:
 bleeding;
 pyogenic infections;
 hypovolaemia;
 fluid, electrolyte, and acid-base disorder
The improper management (e.g. inadequate analgesia or nutritional support,
parenteral nutritional support, pulmonary hypoventilation) is known to contribute to
prolonged catabolic phase as well.
The catabolic phase is a defensive body reaction aimed at enhancing the resistance of
the body by way of prompt transfer of the energetic and plastic materials to the vital
organs.
It is characterised by specific neuroendocrine reactions: activating the sympathetic
nervous system and adrenals, hypothalamus and pituitary, intensive synthesis with
subsequent release of catecholamines, glucocorticoids, aldosterone and ACTH into
the blood. This results in an increase in the amount of glycogen in the circulation,
accompanied by a fall in insulin blood levels. Furthermore, intensive synthesis of
angiotensin and renin occurs.
The neurohumoral disturbances alter the vascular tone to cause vascular spasm and
defects in microcirculation and tissue perfusion, which, in turn, leads to hypoxia,
metabolic acidosis, electrolyte imbalance, fluid redistribution, an increase in blood
viscosity and blood cellular stasis. This further affects the extent of disturbance in the
tissue redox processes that take place in the acceleration of anaerobic glycolysis as a
result of tissue hypoxia. The myocardium, liver and kidneys are therefore the first to
be affected.
The catabolic phase also involves accelerated protein break-down which is
manifested by the decrease in muscle and connective tissue protein, and, which is
even more important, by the depletion in enzymes. The proteolysis in the liver and
digestive tract is the fastest to occur, while that in the striated muscles takes
significantly longer to complete. A 24-hour hunger, for example, decreases the
amount of liver enzymes by 50%. The total loss of body protein during the
postoperative period tends to be considerable. During ten days following uncomplicated stomach resection without parenteral nutritional support, for example,
the patient loses 250 to 400 g of protein, which is twice as much as the amount of
plasma protein and corresponds to the loss of 1,700 to 2,000 g of muscle weight. The
loss of protein appears even greater if bleeding or postoperative purulent
complications develop. This inflicts a particular hazard on those patients who have
been hypoproteinaemic preoperatively.
The clinical specificities of the catabolic phase in the postoperative period
1. Nervous system.
• As a result of the residual action of the narcotic and sedative substances during the
first few days postoperatively, the patient is most likely to be somnolent and
indifferent to his/her surroundings.
•
From the second day the effect of most anaesthetics begins to cease and pain
reactions evolve into unstable psychotic states that can manifest as disorderly
behaviour, anxiety or, alternatively, depression. These are mostly due to
postoperative complications (e.g. progressive hypoxia and fluid and electrolyte
disorders).
2.
Cardiovascular system.
The common cardiologic complications are as follows:
skin pallor;
20 to 30% increase in the pulse rate;
moderate increase in blood pressure;
muffled heart sounds.
3.
Respiratory system.
•
Fast shallow breathing with a reduction in vital capacity by 30-50%.
Shallow breathing can result from the pain at the site of operation, an elevation of the
diaphragm or limitations in its movement after abdominal surgery or development of
paresis of the gastrointestinal tract.
4.
Liver and kidneys.
Progressive dysproteinaemia;
decrease in the synthesis of enzymes;
decrease in urinary output as a result of a fall in renal perfusion and a rise in blood
aldosterone and antidiuretic hormone (ADH) levels.
The resolution phase
The resolution phase commonly lasts 4 to 6 days and is a gradual transition from the
catabolic phase to anabolic one. This period is characterised by the reduction in the
overactivity of the sympathetic nervous system and adrenals, and slowing down
catab-olism which becomes evident as a decrease in nitrogen urinary excretion to as
low as 5—8 g/24 hours (as compared with 15-20 g/24 hours in the catabolic phase).
The positive nitrogen balance (the amount of nitrogen excreted is less than the
amount given) suggests improvement in protein metabolism. In this period,
potassium urinary excretion decreases as the electrolyte starts accumulating to take
part in the synthesis of protein and glycogen. The fluid and electrolyte balance is
restoring. As far as the autonomous nervous and endocrine systems are concerned,
the parasympathetic activity predominates and blood growth hormone (GH) level is
rising, as are those of insulin and androgen.
During the resolution phase, the increased waste of energy and plastic materials
(protein, fat, carbohydrates) is still, though at a somewhat reduced rate, under way.
When this eventually fades away, the active synthesis of protein and glycogen starts
with subsequent production of fat, which rises as the intensity of catabolism falls. The
persistent predominance of anabolism over catabolism is a sign of the transfer of the
postoperative period to the anabolic phase.
The resolution phase occurs 3 to 7 days after the surgery if the postoperative period is
uneventful (i.e. without complications). The signs suggestive of the beginning of the
resolution stage are generally as follows:
absence of pain;
normalisation of body temperature;
resumption of appetite.
In addition, patients become active, and their body functions restore (the skin colour
returns to normal; breathing becomes deep and its rate reduces; the heart rate returns
to the preoperative one; peristaltic bowel sounds and flatus passage resume).
The anabolic phase
The anabolic phase is characterised by an increase in the synthesis of protein,
glycogen, and fat, which have been depleted during the operation and the
postoperative catabolic period. Furthermore, the parasympathetic nervous system
tends to be overactive. Similarly, the secretion of anabolic hormones (GH and
androgens) increases to allow for the protein synthesis. GH, for instance, is
responsible for the transport of amino acids from the intercellular space to the cells,
while androgens promote the synthesis of proteins in the liver, kidneys, and myocardium directly. The specific hormonal responses increase the amounts of protein in
the blood, organs as well as in the wound site, which accounts for the reparative
processes and proliferation and maturation of the connective tissue. During the
postoperative anabolic phase the replenishment of the hepatic and muscular glycogen
stores occurs, which is mediated by the counter insulin action of GH.
Clinically, the anabolic phase is, in fact, the period of recovery, restoration of the
impaired functions of the cardiac, respiratory, excretory, digestive and nervous
systems. In this phase, the patient's general condition improves, appetite increases,
the heart beat and rate return to normal as do the blood pressure levels, and the
digestive functions (food passage, intestinal absorption and spontaneous bowel movements) are restored.
The anabolic phase usually lasts 2-5 weeks, which is dependent on the extent of the
surgery, the patient's state preoperatively as well as the severity and duration of the
catabolic phase.
This phase of the postoperative period ends with an increase in weight, which occurs
after 3—4 weeks and continues till full recovery, which sometimes can take several
months. The restoration of the body weight depends on a number of factors like the
extent of weight loss preoperatively (depending on the nature of the condition), the
extent of the surgery, postoperative complications, the course and duration of the
postoperative catabolic phase. It usually takes 3 to 6 months for the reparative
process (i.e. maturation of the connective tissue and formation of the scar) to
complete.
Immediately after operation the patient is transferred either to the ward or intensive
care unit which are arranged to monitor the patients and, if needed, to provide them
with emergency and intensive care. These units are equipped with gadgets and
appliances that constantly record the pulse rate and rhythm, ECG, EEG. The
emergency laboratory ensures a prompt monitoring of blood haemoglobin,
haematocrit, electrolyte and protein levels, as well as circulating blood volume and
acid-base balance. The intensive care unit is also equipped with all that is necessary
to provide the emergency aid: medications and transfusion fluids, a mechanical
ventilation apparatus, sterile sets for venous injections or infusions and tracheostomy,
defibrillator, sterile catheters, tubes, a set for change of dressing.
In the postoperative period, the patient is to be examined thoroughly using the
general physical methods (inspection, palpation, percussion, auscultation) and,
whenever necessary, laboratory investigations (e.g. ECG, X-ray, EEG). Each patient
should be constantly monitored both for psychotic signs (consciousness, behaviour
changes such as excitement, depression, delirium, hallucination) and skin condition
(pallor, cyanosis, jaundice, dryness and perspiration).
Examining the cardiovascular system, the physician will pay attention to the pulse
rate, character and rhythm, as well as blood pressure levels and, if pertinent, those of
the central venous pressure; the character of the heart sounds and the presence or
absence of murmurs.
The respiratory system is assessed by way of percussion and auscultation: the rate,
depth and rhythm of breathing are taken into consideration.
The evaluation of the gastrointestinal tract involves inspection of the tongue (dryness,
fur), inspection and palpation of the abdomen (distension, involvement in breathing,
signs of peritoneal irritation like the symptom of defence of the abdominal wall
muscles or rebound tenderness, the presence of bowel sounds), the liver is palpated
for its enlargement and tenderness. The patient is to be asked of the passage of flatus
and stools as well.
The examination of the urinary system includes the determination of diurnal urine
volume and urine output through the permanent catheter.
The clinical and laboratory findings (haemoglobin level, haematocrit, metabolic
indicators, circulating blood volume, blood electrolytes, etc.) should be meticulously
scrutinised as this helps determine the type and amount of transfusion fluid as well as
prescribe the appropriate drugs.
The patient should be examined on a regular basis as this enables the physician to
reveal the early signs of deterioration and therefore duly adjust the current therapy.
All the clinical and laboratory findings are liable to be recorded in a special chart of
observation at the intensive care unit, and also in the patient's case history.
When monitoring the patient, the physician uses specific criteria to determine the
cause of the vital organs' deterioration:
1.
The cardiovascular system:
pulse rate above 120 beats per minute;
fall (J80 mm Hg) and rise (i200 mm Hg) in systolic blood pressure;
cardiac arrhythmia;
reduction (<50 mm of H20) and elevation (>110 mm H20) in the central venous
pressure.
2.
The respiratory system:
respiratory rate above 28 per minute;
extremely dull percussion notes, all over the lung;
the absence of breath sounds over the dull areas.
3.
The skin and visible mucous membranes:
extreme pallor;
acrocyanosis;
cold sticky sweat.
4.
The urinary system:
decrease in urine production (< 10 ml per hour);
anuria.
5.
The gastrointestinal tract:
defencive rigidity of muscles of the anterior abdominal wall;
black stools, occult blood in the stools;
vivid rebound tenderness;
abdominal distention;
•
absence of flatus and bowel sounds for more than 3 days.
6.
The central nervous system:
•
loss of consciousness, delirium, hallucinations;
excessive talking, speech and motion excitement;
depression.
7.
The state of the operation wound:
profuse blood staining of the wound dressing;
gapping of the wound edges;
evisceration (eventration) of the abdominal organs into the wound;
profuse soaking of the dressing with pus or intestinal contents.
The treatment consists in compensation of metabolic disorders, restoration of the
body functions, normalisation of the redox reactions in the tissues — oxygen transfer,
elimination of the products of incomplete metabolism and carbon dioxide and replenishment of the increased energy waste. Parenteral and, whenever possible, enteral
nutritional support is a very important method to improve and maintain of the protein
and electrolyte balance. It is advisable to give fluids and nutrients by the natural way
and try to implement this as early as possible.
The following are important hints on intensive therapy of the postoperative patient:
Relief of pain with analgesics, electro-analgesia, peridural anaesthesia, etc.
Restoration of the cardiovascular functions, correction of the deficient
microcirculation (cardiovascular drugs and rheopolyglucan).
Prevention and treatment of respiratory insufficiency (oxygen therapy, breathing
gymnastics, controlled breathing).
Detoxication therapy.
Correction of the metabolic imbalance (fluid, electrolyte balance, acid-base balance,
protein synthesis).
Balanced parenteral nutritional support.
Restoration of the urinary system functions.
Restoration of the body functions affected by the surgery (intestinal paresis in
abdominal interventions, pulmonary hypoventilation or atelectasis in respiratory
operations, etc.).
Complications may develop in the early postoperative period (before the patient has
been discharged from the surgical unit).
During the first two days postoperatively the following complications can be
encountered:
bleeding (internal or external);
acute circulatory failure (shock);
cardiac arrest;
asphyxia, respiratory failure;
complications of anaesthesia;
fluid and electrolyte disorders;
failure of the urinary system (oliguria, anuria);
gastric or intestinal paresis.
On the subsequent days (days 3—8) there is a high risk of congestive heart failure,
pneumonia, thrombophlebitis, thromboembolism, acute liver failure and wound
infection.
After the patient has been discharged from the hospital (late postoperative period)
complications can arise from the organs which have been operated on (e. g. as a result
of gastric resection, postcholecystectomy, abdominal adhesions). Some other complications are not infrequent: ligature fistula (stitch abscess), postoperative hernia,
keloid cicatrix.
BIBLIOGRAPHY
1. Black. Medical Surgical Nursing-Clinical Management for Continuity of care
7/e 2 Vol Set 2004.
2. Bloom. Toohey’s Medicine 15/e. 1994.
3. Colmer. Moroney’s Surgery for the Nurses. 16/e. 1996.
4. Lewis. Medical Surgical Nursing. 7/e. 2007.
5. Pierce. Management of the Mechanically Ventilated Patient. 2/e. 2007.
6. Sirra. Nursing Process. 2/e. 2005.
7. Potter. Basic Nursing. 6/e. 2006.
8. Sharma. Diet Management. 3/e. 2004.
9. Joshi. Essentials of Orthopaedics & Applied Physiotherapy. 1999.
10.Kotwal. Textbook of Orthopaedics. 2005.
11.Ghosal. Practicals & Viva in Surgery. 2004.
12.Goljan. Most Commons in Surgery. 2001.
13.Kapur. Manual of Surgical Instruments and Procedures. 1998.
14.Rosai. Rosai & Ackerman’s Surgical Pathology. 9/e. 2004.
15.Townsend. Sabiston Textbook of Surgery. 17/e. 2004.
ПРЕДОПЕРАЦИОННЫЙ ПЕРИОД. ОПЕРАЦИЯ.
ПОСЛЕОПЕРАЦИОННЫЙ ПЕРИОД
Учебное пособие для студентов лечебного факультета англоязычного
отделения
PREOPERATIVE PERIOD. OPERATION. POSTOPERATIVE PERIOD
Textbook for Students of General Medicine in the English-speaking Medium
Cоставители:
Владимирова О.В., ассистент кафедры общей хирургии Ставропольской
государственной медицинской академии.
Линченко В.И., к.м.н., ассистент кафедры общей хирургии
Ставропольской государственной медицинской академии.
Сдано в набор 2009г. Подписано в печать
2009 г.
Формат . Бумага офсетная. Печать
. Гарнитура Times New Roman/
Усл. печ. л. Уч.-изд. л. .
Заказ . Тираж 200
Отпечатано с оригинал-макета, предоставленного заказчиком